Earlier this summer, I wrote about “summer SAD,” the very real worsening of mood, anxiety, agitation, and sleep that some people experience during the hottest and brightest months of the year.

After this weekend, I think the conversation needs to go further. Temperatures in the Sacramento area have exceeded 100°F, and over the past several days I have seen multiple previously stable patients experience abrupt and clinically significant psychiatric destabilization.

One patient …

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Patient details have been changed and combined where necessary to protect privacy.

This week, I evaluated two young people who had recently been hospitalized after developing psychosis in the setting of heavy cannabis use. Both had been discharged with serious psychiatric diagnoses and multiple medications. Both families were frightened. And in both cases, the central clinical question remained insufficiently answered: Was this the onset of a primary psychiatric disorder, or was …

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When most people hear the words seasonal affective disorder, they picture winter. Dark mornings. Short days. Cold weather. Fatigue. Oversleeping. Wanting to stay under the covers. Only wanting to go out for donuts.

But seasonal depression does not always come in winter. For some people, summer is the difficult season. And summer-pattern seasonal affective disorder can look very different from the winter depression most of us recognize. Instead of slowing down, …

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When a child is diagnosed with ADHD, the conversation is often much narrower. Medication. Maybe a school form. Maybe a vague suggestion to “try therapy.” Then parents are sent back into the same exhausted home, the same chaotic mornings, the same homework battles, the same social struggles, the same emotional explosions, and the same school system that often does not know what to do with a child who is bright, …

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Adult ADHD is real. It is impairing. It is often missed, especially in bright, high-achieving adults, women, and people who learned to compensate for years before finally burning out. But the solution to underdiagnosis cannot be overdiagnosis.

We are now seeing a second problem emerge: rushed adult ADHD evaluations, often completed in 30 to 60 minutes, sometimes based heavily on a brief questionnaire, followed quickly by stimulant prescribing. The patient may …

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One of the hardest parts of practicing psychiatry is that we still cannot reliably predict which medication will work for which patient.

A patient comes in struggling with depression. We choose a medication based on symptoms, history, side effect profile, family history, clinical experience, and sometimes educated guesswork. Then we wait. Sometimes the medication helps quickly. Sometimes it causes side effects. Sometimes nothing happens at all. Then we adjust, augment, switch, …

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In clinical practice, it is not uncommon for autistic patients to arrive after years of treatment with a firm conclusion: Psychiatric medications do not work for them. This belief is typically built on multiple medication trials, inconsistent benefit, and often significant side effects. But the conclusion itself may be misleading. What is often being observed is not true treatment resistance, but a mismatch between standard psychopharmacology and the neurobiology of …

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Bree is an 11 1/2 year-old, 4.2-pound micro mutt who once lived on the streets of Long Beach. She eventually wound up at Long Beach Animal Care Services, where she sat in a crowded cold cement kennel with no bed, no blanket, no toys, and one very sick basset hound with parvovirus. Every dog in that kennel was scheduled to be euthanized on Christmas Eve 2014. If it weren’t for …

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A patient in his 20s recently came to see me in a state of severe distress. He described feeling consumed by his thoughts, constantly anxious, unable to function, and deeply exhausted. His sleep had collapsed. His sense of identity felt lost. He was experiencing persistent passive suicidal thoughts, not because he wanted to die, but because everything felt overwhelming and unrelenting.

Within three days of starting low-dose lithium at 150 milligrams …

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She was 16 the first time she noticed it. Milk. From her breasts. No pregnancy. No childbirth. No explanation. She told a provider. Labs were drawn. Her prolactin was elevated. She was told it was “not a big deal.” Over the years, multiple providers suggested she must be stimulating her nipples and advised her to stop. She insisted she was not. She felt embarrassed, dismissed, and increasingly reluctant to bring …

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When my father-in-law died by suicide, our family did not just lose a person. We lost the gravitational center of a small universe.

He was a giant in my eyes. Not because of his curriculum vitae, though his was extraordinary, but because of the way he moved through the world: steady, modest, and relentlessly devoted to the people who needed him.

He had survived what should have broken a human being. As …

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Over the past decade, there has been a marked rise in adolescents and adults seeking autism evaluations. Many of these individuals are intellectually intact, verbally fluent, and professionally capable, yet have lived for decades with persistent social fatigue, sensory sensitivities, difficulty interpreting unspoken social rules, emotional overwhelm, rigid or all-or-nothing thinking, challenges with transitions, and extensive masking or camouflaging behaviors, all without a diagnosis. When they finally seek clarity, the …

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Stimulant medications have long been considered the “gold standard” for treating ADHD. When I tell colleagues I don’t prescribe them, I often get pushback: “But it’s the first-line treatment for ADHD!” In my functional and integrative psychiatry practice, I am upfront: I do not prescribe stimulants for ADHD. For patients who are interested in stimulant treatment, I provide referrals to trusted colleagues who do. This decision is not about denying …

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